Healthcare Provider Details

I. General information

NPI: 1235138496
Provider Name (Legal Business Name): ELIZABETH G SYBRANDY-NICELY DPM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: LISA G NICELY DPM

II. Dates (important events)

Enumeration Date: 07/20/2005
Last Update Date: 10/29/2024
Certification Date: 10/29/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1001 SHROYER RD
DAYTON OH
45419-3635
US

IV. Provider business mailing address

6200 PLEASANT AVE SUITE 3
FAIRFIELD OH
45014-4670
US

V. Phone/Fax

Practice location:
  • Phone: 937-264-3150
  • Fax: 513-858-7827
Mailing address:
  • Phone: 937-293-8448
  • Fax: 937-617-4840

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number2389
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: